Patricia Schofield

Chronic pain can contribute to disability, depression, anxiety, sleep disturbances, poor quality of life and increased health care costs, with close to 20 % of the adult population in Europe reporting chronic pain. To empower the person to self-manage, it is advocated that education and training about the nature of pain and its effects and how to live with pain is provided. The objective of this review is to determine the level of evidence for education to facilitate knowledge about chronic pain, delivered as a stand-alone intervention for adults, to reduce pain and disability. We identified randomised controlled trials of educational intervention for chronic pain by searching CENTRAL, MEDLINE, EMBASE and ongoing trials registries (inception to December 2013). Main inclusion criteria were (1) pain >3 months; (2) study design that allowed isolation of effects of education and (3) measures of pain or disability. Two reviewers independently screened and appraised each study. Nine studies were analysed. Pooled data from five studies, where the comparator group was usual care, showed no improvement in pain or disability. In the other four studies, comparing different types of education, there was no evidence for an improvement in pain; although, there was evidence (from one study) of a decrease in disability with a particular form of education—pain neurophysiology education (PNE). Post-hoc analysis of psychosocial outcomes reported in the studies showed evidence of a reduction in catastrophising and an increase of knowledge about pain following PNE. The evidence base is limited by the small numbers of studies, their relatively small sample sizes, and the diversity in types of education studied. From that limited evidence, the only support for this type of education is for PNE, though it is insufficiently strong to recommend conclusively that PNE should be delivered as a stand-alone intervention. It therefore remains sensible to recommend that education be delivered in conjunction with other pain management approaches as we cannot confidently conclude that education alone is effective in reducing pain intensity or related disability in chronic pain in adults.

The Engaging with older adults in the development of strategies for the self management of chronic pain (EOPIC) study aims to design and develop self management strategies to enable older adults to manage their own pain. Involving older adults in research into chronic pain management will better enable the identification and development of strategies that are more appropriate for their use, but how can perspectives really be utilised to the best possible outcomes? Seven older adults were recruited through a local advertising campaign to take part. We also invited participants from the local pain services, individuals who had been involved in earlier phase of the EOPIC study and a previous ESRC funded project. The group undertook library training and research skills training to facilitate searching of the literature and identified sources of material. A grading tool was developed using perceived essential criteria identified by the older adults and material was graded according to the criteria within this scale. Fifty-seven resources from over twenty-eight sources were identified. These materials were identified as being easily accessible, readable and relevant. Many of the web based materials were not always easy to find or readily available so they were excluded by the participants. All but one were UK based. Forty-four items were identified as meeting the key criteria for inclusion in the study. This included five key categories as follows; books, internet, magazines, leaflets, CD’s/Tapes. This project was able to identify a number of exemplars of self management material along with some general rules regarding the categories identified. We must point out that the materials identified were not age specific, were often locally developed and would need to be adapted to older adults with chronic pain. For copyright issues we have not included them in this paper. The key message is really related to the format rather than the content. However, the group acknowledge that these may vary according to the requirements of each individual older adult and therefore recommend the development of a leaflet to help others in their search for resources. This leaflet has been developed as part of Phase IV of the EOPIC study.

Summary: A number of recent reports have highlighted the inadequate provision of pain relief for older inpatients. Despite the availability of numerous validated pain measures, pain remains poorly assessed in some cases and, particularly, in the cognitively impaired. Without proper assessment, patients may receive inadequate or inappropriate analgesia, both of which can worsen outcome. Most drugs and techniques that are used for analgesia in younger patients are also suitable for older patients, although dosages may have to be adjusted to avoid the side‐effects that are consequent upon age‐related changes in drug pharmacokinetics and pharmacodynamics, co‐morbidity, frailty, cognitive impairment and polypharmacy. This paper reviews current guidelines and methods of assessing pain in the older adult, and describes the use of, and problems with, mild, moderate, strong, adjuvant and local anaesthetic drugs in the older population for analgesia, advocating multimodal intervention to reduce dose‐related side‐effects, particularly of opioids.

Over 50% of older adults experience chronic pain. Poorly managed pain threatens independent functioning, limits social activities and detrimentally affects emotional wellbeing. Yet, chronic pain is not fully understood from older adults’ perspectives; subsequently, pain management in later life is not necessarily based on their priorities or needs. This paper reports a qualitative exploration of older adults’ accounts of living with chronic pain, focusing on how they describe pain, with a view to informing approaches to its assessment. Cognitively intact men and women aged over sixty-five who lived in the community opted into the study through responding to advertisements in the media and via contacts with groups and organisations in North-East Scotland. Interviews were transcribed and thematically analysed using a framework approach. Qualitative individual interviews and one group interview were undertaken with 23 older adults. Following analysis, the following main themes emerged: diversity in conceptualising pain using a simple numerical score; personalising the meaning of pain by way of stories, similes and metaphors; and, contextualising pain in relation to its impact on activities. The importance of attending to individuals’ stories as a meaningful way of describing pain for older adults is highlighted, suggesting that a narrative approach, as recommended and researched in other areas of medicine, may usefully be applied in pain assessment for older adults. Along with the judicious use of numerical tools, this requires innovative methods to elicit verbal accounts, such as using similes and metaphors to help older adults describe and discuss their experience, and contextualising the effects of pain on activities that are important to them.